A judge in Texas struck down part of a law designed to protect Americans from surprise medical bills, and the Biden administration plans to appeal that ruling. The court case has major potential implications for how billing works for medical care.
Surprise bills
One of the most financially dangerous parts of the American health care system is surprise billing. Surprise billing is when a person gets an unexpectedly high bill for care because one or more of the providers involved was not in the same network as their insurance. Insurance companies cover fewer services from out-of-network providers.
Under the No Surprises Act, the charges in cases like these become the responsibility of the care provider and the patient’s health insurance plan, who work out the issue through a dispute resolution process. The Department of Health and Human Services sent out a rule illustrating how that dispute process is supposed to work, but the rule attracted lawsuits from care provider groups.
Legal changes
If the Biden administration loses its appeal, Health and Human Services will need to write a new procedure under health care law for how to manage provider-insurer disputes. It will still take time to work out the legislation and guidance for how the providers and insurance companies are supposed to manage disputes for what otherwise would be surprise bills. Without that defined arbitration method in the HHS rule, it is not easy for the providers and insurers to settle the responsibility for billing.
Since out-of-network billing involves large charges, it is critical that the insurance companies and care providers have a process to manage how they divide the burden of paying the leftover bills.